Awanas 2019

Name *

First Name Last Name

Address *

Street Address

Street Address 2

City State / Province

Postal / Zip Code

Birthdate *

mm/dd/year

Age (as of Sept. 1) *

Gender *

School Child attends (if in school)

Grade

Father's Name

Father's Phone Number

Mother's Name

Mother's Phone Number

Emergency Contact #1 Name (other than mom & dad) *

Emergency Contact #1 Phone Number *

Emergency Contact #2 Name (other than mom & dad) *

Emergency Contact #2 Phone Number *

Allergies

Any other information that is helpful please provide below:

Awanas Fee:

$15 for 1 child

$20 for 2 children in one family

Please make sure to pay these fees to Kara Cook before or at the first Awana meeting on Sept. 15.

*For more than 2 children, please see Kara.

I give Hagood Avenue Baptist Church permission to use photo's or videos for promotional reasons and/or on church website/facebook.

I hereby authorize any licensed physician or medical treatment center to treat my child in case of an emergency in which neither parent can be reached. *

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The undersigned participant and, if participant is a minor, the legal custodian thereof, hereby consent of the participation of participant in the above-referenced activity conducted under the sponsorship of Hagood Avenue Baptist, Barnwell County, South Carolina, an incorporated organization; its agent, servant, and member. In making such consent, participant and custodian acknowledge that they understand that there are risks to both person and property associated with engaged in such activity, and they hereby consent to assume such risk. In consideration of granted permission by Hagood Ave. Baptist Church, its agents, servants, and members for the participation in such activity by participant and custodian hereby, release and exonerate Hagood Avenue Baptist, its agents, servants, and members from any and all liability of every nature and kind pertaining to such activity or the participation therein by participant. Participant and custodian hereby authorize and consent to any x-ray examination, anesthesia, medical or surgical diagnosis or treatment, and hospital care to be rendered to participant under the general or special supervision, and on the advice of a licensed physician, surgeon, anesthesiologist, dentist, or othere qualified medical personnel acting under their supervision.The consent, waiver, and release provisions hereof shall remain in full force and effect until written notice of revocation or withdrawal is received by Hagood Avenue Baptist Church at its office at 1144 Hagood Avenue, Barnwell County, South Carolina. *

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